Provider Demographics
NPI:1891808143
Name:DIAZ, GLORIA M
Entity Type:Individual
Prefix:MISS
First Name:GLORIA
Middle Name:M
Last Name:DIAZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 W 4TH ST
Mailing Address - Street 2:SUITE 6
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19805-3367
Mailing Address - Country:US
Mailing Address - Phone:302-482-3388
Mailing Address - Fax:302-482-3389
Practice Address - Street 1:2500 W 4TH ST
Practice Address - Street 2:SUITE 6
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19805-3367
Practice Address - Country:US
Practice Address - Phone:302-482-3388
Practice Address - Fax:302-482-3389
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2016-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DELG0000346363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
DEG33068Medicare UPIN
DE802529ZE6Medicare PIN